OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents for 2 of 2 sampled residents (#s 1 and 3) who were prescribed modified texture diets. The residents’ prescribed diets were not administered by the facility, placing them at risk of aspiration, choking and/or death. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 07/2026 with diagnoses including dementia, bladder cancer and Stage 3 kidney disease. Review of the resident’s clinical record identified the resident was prescribed a modified Level 6 diet texture. According to the International Dysphagia Diet Standardization Initiative (IDDSI), a level 6 diet texture requires food particles to be cut into 1.5 cm by 1.5 cm pieces, tender and soft, not crunchy, require no biting and to be moist with no separate thin liquids. The food should easily mash with a fork, passing through the tines prior to the holder’s thumbnail blanching white. During breakfast meal observation on 08/18/26 at 10:45 am, the resident was served the following food items: * Full length sausage links; * Cereal with crunchy flakes, raisins and milk partially covering the dry cereal; and * A slice of French toast with pieces cut larger than 1.5 cm by 1.5 cm with a dish of syrup on the side. During an interview on 08/18/26 at 3:38 pm, Resident 1’s modified diet texture orders were discussed with Staff 1 (Administrator) and Staff 2 (RN). Staff 2 began looking up the instructions for a Level 6 modified diet on the IDDSI website. During an interview on 08/19/26 at 9:25 am, Staff 5 (CG), who prepared the meal in the MCC kitchenette, reported care staff were not aware of the requirements for Resident 1’s modified diet and were not provided training on how to prepare a Level 6 modified diet. Staff 5 stated, “I thought we just cut it up small into bite-sized pieces.” During breakfast meal observation on 08/19/26 at 9:45 am, the resident was served sausage links cut into 2 cm pieces. During lunch meal observation on 08/19/26 at 1:07 pm, the resident was served pork that had pieces larger than 1.5 cm by 1.5 cm with pasta noodles in a sauce covering part of the noodles. The remaining noodles were dry. Prior to the meal being served to Resident 1 an observation of the plate was completed with Staff 1, Staff 2, Staff 8 (Skilled Nursing Facility Dietary Manager) and Staff 9 (ED). Staff 8 stated the meal was served at a Level 6 modified diet texture and that it was “soft and bite sized.” When asked if the soft and bite sized pieces of pork were 1.5 cm x 1.5 cm, Staff 8 replied “I don’t know.” Surveyor proceeded to complete a fork pressure test with facility staff to confirm the pork was soft and tender. The fork pressure test failed, bending the metal fork. The facility failed to provide the prescribed diet texture for the resident, which placed him/her at risk of choking, aspiration, and/or death. An immediate plan of correction was requested on 08/19/26 at 2:22 pm. The facility provided a plan of correction on 08/19/26 at 5:35 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety or welfare of residents was discussed with Staff 1, Staff 2, and Staff 9 on 08/19/26 at 2:22 pm. They acknowledged the findings. 2. Resident 3 moved into the MCC in 4/2026 with diagnoses including dementia. During the acuity interview on 08/17/26, it was reported the resident was receiving hospice services, was on a mechanically soft diet and dependent on staff for meal assistance. Review of Resident 3’s clinical record identified prescriber diet orders dated 08/13/26 for pureed texture with thin liquids. During an interview on 08/19/26 at 9:20 am, Staff 3 (MT) reported Resident 3 had French toast “cut into small pieces, but that was before we knew about the consistency and about no bread or syrup. We didn’t know s/he changed to puree. Honestly, I don’t know what level [diet order] exactly s/he was before [the order changed to puree].” An immediate plan of correction was requested on 08/19/26 at 2:22 pm. The facility provided a plan of correction on 08/19/26 at 5:35 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2, and Staff 9 on 08/19/26 at 2:22 pm. They acknowledged the findings.

C160 OAR 411-054-0025 (4) Reasonable Precautions 1. Actions taken to correct the rule violation as follows: a. Resident #1: The resident's current diet order was reviewed and clarified. The MAR, service plan, and nutrition/hydration plan were reviewed and updated to accurately reflect the resident's prescribed Level 6 Soft & Bite-Sized diet. Direct care and dietary staff were educated regarding the resident's prescribed diet, including appropriate food size, texture, moisture requirements, and appropriate IDDSI testing methods. Staff responsible for meal preparation and service demonstrated understanding of the resident's diet requirements. b. Resident #3: The resident's current prescriber diet order for pureed texture with thin liquids was reviewed and verified. The MAR, service plan, and nutrition/hydration plan were reviewed and updated to accurately reflect the current diet order. Direct care and dietary staff were educated regarding preparation and service of the resident's prescribed pureed diet and thin liquids. c. The Licensed Nurse/RCC and Dietary Manager reviewed all residents with modified-texture diet orders to verify that current provider orders are accurately reflected on the MAR, service plan, nutrition/hydration plan, and dietary information available to staff. Any discrepancies identified were corrected. 2. The system will be corrected so this violation will not happen again by: a. All new and changed diet orders will be reviewed upon receipt and communicated to staff responsible for preparing and serving meals prior to the resident's next meal. The Licensed Nurse/RCC will verify that the resident's current diet order is accurately reflected on the MAR, service plan, nutrition/hydration plan, and dietary communication tools. b. All direct care and dietary staff responsible for preparing or serving modified-texture diets will receive training regarding modified-texture diets, including applicable IDDSI requirements, food preparation, texture, particle size, moisture requirements, and appropriate testing methods. c. Newly hired staff responsible for preparing or serving modified-texture diets will receive training prior to independently preparing or serving these diets. 3. The area needing correction will be evaluated: a. The Licensed Nurse, RCC, Dietary Manager, Administrator, or trained designee will conduct meal observations of residents receiving modified-texture diets weekly for four weeks and monthly for three months to verify that meals served are consistent with the resident's current prescribed diet texture and liquid consistency. b. New or changed diet orders will be reviewed upon receipt to ensure the order has been accurately communicated and incorporated into the resident's MAR, service plan, nutrition/hydration plan, and dietary information. c. Results of audits and meal observations will be reviewed through the facility's Quality Improvement process. Any identified concerns will be corrected immediately and additional staff education provided as indicated. 4. The Facility Administrator, Licensed Nurse, RCC, & Dietary Manager will ensure corrections are completed & monitored.

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure medication errors were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out for 1 of 1 sampled resident (# 1) who was reviewed with ongoing medication errors. Findings include, but are not limited to: Resident 1 moved into the MCC in 07/2026 with diagnoses including dementia, bladder cancer and Stage 3 kidney disease. During the acuity interview on 08/17/26, it was reported the facility was responsible for administering all medications and treatments. Review of the resident’s clinical record, including the 07/07/26 through 08/17/26 MARs and current prescriber orders, identified the following: * The resident was prescribed Eliquis (anticoagulant to prevent blood clots) 5 mg tablet, twice per day; and * From 07/07/26 through 08/17/26, the resident was administered a 5 mg tablet once per day. The facility failed to complete an investigation for the medication error and was not aware of the medication error until it was discovered by the survey team on 08/18/26. Surveyor requested the facility self-report the medication error to the local Department office. Verification of reporting was received on 08/18/26 at 4:42 pm. The need to ensure medication errors were promptly investigated to rule out abuse and/or neglect and reported to the local Department office if abuse could not reasonably be ruled out was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/18/26 at approximately 4:00 pm. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure infection and prevention protocols were maintained during ADL care for 1 of 1 Resident (#1) who received catheter care. The findings include, but are not limited to: Resident 1 moved into the MCC in 07/2026 with diagnoses including dementia, bladder cancer and Stage 3 kidney disease. During the acuity interview on 08/17/26, it was reported the facility was responsible for catheter care management. With permission from the resident, Staff 4 (CG) and Staff 5 (CG) were observed providing ADL care on 08/19/26 at 9:30 am. Upon entering the resident’s unit, the catheter bag was observed hanging over the foot of the bed and touching the ground. Staff 4 donned cleaned gloves and began removing dirty clothing, including socks worn the previous day. The CG stopped removing the dirty clothing and started looking around, opening several drawers looking for alcohol swabs. Once the alcohol swabs were found she obtained a urinal, cleaned the drain tube with an alcohol swab while wearing soiled gloves, drained the urine from the drainage bag into the urinal. She walked into the bathroom, dumped the urine into the toilet and removed the soiled gloves. She placed clean gloves on without performing hand hygiene. Staff 5 removed the resident’s soiled pants and Staff 4 removed the residents’ soiled incontinent brief. With the same soiled gloves on, Staff 4 placed a clean incontinent brief on the resident and assisted with running the drainage bag and tubing down the resident’s pant leg and pulling the residents pants up just above the knees. Staff 4 and 5 assisted the resident to stand while the drainage bag fell on the floor. While still wearing soiled gloves, Staff 4 pulled the residents pants up to his/her waist and proceeded to remove a dirty shirt and place a clean shirt on the resident. During the process of undressing and dressing the resident, Staff 4 stepped on the drainage bag and tubing twice. Staff 4 and 5 completed the transfer into the wheelchair. Staff 5, while wearing soiled gloves, was observed running her fingers through the resident’s hair attempting to straighten the back of the resident’s hair before placing a hat on him/her. Staff 4 picked up the soiled brief, threw it in the trash can and proceeded to place a clean disposable incontinence pad on the resident’s bed. She then made the bed while continuing to wear the soiled gloves. Once completed she doffed the soiled gloves, placed them in the trash and was seen taking the trash to the laundry room, coming back out and walking into the kitchenette before she performed hand hygiene. Staff 5 was observed escorting the resident by wheelchair out to the living room for breakfast. Staff 5 still had the same soiled gloves on, and the drainage bag was dragging onto the floor. Staff 5 removed her gloves and was not seen performing hand hygiene. The need to ensure staff followed infection prevention protocols during all ADL care was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/20/26 at approximately 1:00 pm. They acknowledged the findings.

C295 OAR 411--54-0050 (1-5) Infection Prevention & Control 1. Actions taken to correct the rule violation as follows: a. Employees #4 and #5 completed the following Oregon Care Partners trainings: • About Infection Control & Prevention – 1 hour • Infection Control: Key Concepts and Practices – 15 minutes b. Employees #4 and #5 received additional education from the Licensed Nurse regarding proper hand hygiene, appropriate glove use and glove changes, donning and doffing of PPE, prevention of cross-contamination, and proper catheter drainage bag and tubing management during ADL care. c. Resident #1's catheter care needs and service plan were reviewed by the Licensed Nurse to ensure staff instructions accurately reflect the resident's catheter care and infection-prevention needs. d. All direct-care staff will receive education regarding infection prevention and control, including hand hygiene, appropriate glove use and glove changes, prevention of cross-contamination, donning and doffing PPE, and catheter care. Skills observations will be completed by the Licensed Nurse by 9/11/26. 2. The system will be corrected so this violation will not happen again by: a. The facility will reinforce its infection prevention and control protocols with all direct-care staff. Staff will be required to perform hand hygiene at appropriate times during resident care, including after removal of contaminated gloves and before donning clean gloves when indicated. Gloves will be changed when moving from a contaminated task to a clean task to prevent cross-contamination. b. Staff providing catheter care will be trained to maintain urinary drainage bags and tubing in a manner that prevents contact with the floor and contamination during ADL care, transfers, and mobility. c.The Licensed Nurse, Infection Control Specialist, or trained designee will validate staff competency through direct observation of infection-control practices during resident care. Any staff member who does not demonstrate competency will receive immediate re-education and repeat skills validation. 3. The area needing correction will be evaluated: a. The Licensed Nurse, Infection Control Specialist, Administrator, RCC, or trained designee will complete infection-control observations during resident care weekly for four weeks and monthly for three months. b. Observations will include, as applicable, hand hygiene, appropriate glove use and glove changes, prevention of cross-contamination, PPE use, catheter drainage bag/tubing management, and infection-control practices during ADL care. c. Any deficient practice identified will be corrected immediately, with re-education and repeat competency observation as indicated. Results and trends will be reviewed through the facility's Quality Improvement process. After the initial monitoring period, infection-control practices will continue to be monitored through routine facility oversight and the Quality Improvement program. 4. The Facility Administrator, Infection Control Specialist, Licensed Nurse, RCC, or trained designee will be responsible for ensuring corrective actions are completed, staff training and competency validation are documented, infection-control observations are completed, and identified concerns are corrected.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a safe medication and treatment system with adequate professional oversight. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on the scope and deficiencies in the following areas: C 303: Systems: Medication and Treatment Orders; and C 310: Systems: Medication Administration. The need to ensure adequate professional oversight of the medication and treatment system was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/20/26 at approximately 1:00 pm. They acknowledged the findings.

C300 OAR 411-054-0055(1)(a) Systems: Medications and Treatments Please refer to the following deficiencies in the Plan of Correction under C300 to ensure a safe medication system and adequate professional oversight: *C303 Medication and Treatment Orders *C310 Medication Administration

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure orders were carried out as prescribed for 2 of 2 sampled residents (#s 1 and 3) whose prescriber orders were reviewed. Resident 1 had ongoing medication errors for an anticoagulant medication which put the resident at risk of blood clots, and Residents 1 and 3 had modified diet text orders that were not carried out as prescribed which put the residents at risk of choking, aspiration, and/or death. Findings include, but are not limited to: 1. Resident 1 moved into the MCC in 07/2026 with diagnoses including dementia, bladder cancer, Stage 3 kidney disease and deep vein thrombosis (DVT). During the acuity interview on 08/17/26 it was reported the facility was responsible for administering all medications and treatments. The resident’s clinical record including the 7/7/26 through 08/17/26 MAR’s, current prescriber orders and progress notes dated 07/07/26 through 08/17/26 were reviewed. a. The following oral medications were not administered as prescribed: * The resident was prescribed Eliquis (anticoagulant to prevent blood clots) 5 mg tablet, twice per day; and * From 07/07/26 through 08/17/26, the resident was administered a 5 mg tablet once per day. Staff documented on 07/10/26, “resident has swelling and discoloration to the left arm and left leg about 10:10 pm. [S]ent resident to the hospital for history of blood clots.” The resident returned to the MCC on 07/10/26 and the facility continued to administer the incorrect dose of Eliquis until survey discovered the medication error on 08/18/26. The ongoing Eliquis medication error put the resident at risk for a blood clot. The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/18/26 at approximately 4:00 pm. They acknowledged the findings. b. The following treatment was not carried out as prescribed: * The resident was prescribed a Level 6 modified diet texture; and * The facility did not consistently prepare meals according to the modified diet texture. The facility failed to administer Resident 1’s prescribed modified diet texture, placing him/her at risk of aspiration, choking, and/or death. Refer to C 160, example 1. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/20/26 at approximately 1:00 pm. They acknowledged the findings. c. Resident 1 was prescribed PRN Tylenol and PRN tramadol, both for pain. A nursing parameter instructed unlicensed staff to administer the PRN Tylenol before the PRN tramadol. On 08/03/26 and 08/13/26, unlicensed staff administered the tramadol prior to administering the Tylenol. The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/20/26 at approximately 1:00 pm. They acknowledge the findings. 2. Resident 3 moved into the MCC in 4/2026 with diagnoses including dementia. During the acuity interview on 08/17/26, it was reported the resident was receiving hospice services, was on a mechanical soft diet and dependent on staff for meal assistance. Review of Resident 3’s clinical record identified prescriber diet orders dated 08/13/26 for pureed textures with thin liquids. The facility failed to follow the puree diet texture from 08/13/26 until survey identified the treatment error during the survey. Resident 3’s prescribed modified diet texture was not administered by the facility, placing him/her at risk of aspiration, choking, and/or death. The need to ensure the facility carried out orders as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/19/26 at approximately 9:56 am and on 08/20/26 at approximately 1:00 pm. They acknowledged the findings. Refer to C 160, example 2.

C303 OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders 1. Immediate actions taken to correct this rule violation A. Resident #1 a) 8/18/26 the Eliqus order was updated to reflect the provider order of one tablet by mouth twice daily. RN assessment was completed, and an incident report was completed with notification to APS. b) Refer to C160, the diet was clarified, education was provided to the direct care staff, order was updated on the MAR, service plan and hydration / nutrition plan were updated to reflect the accurate diet. c) 9/3/26 incident reports were competed for 8/3/26 & 8/13/26 for administration of Tramadol prior to administration of Tylenol as per the parameters on the orders. Training was completed by licensed nurse for following nursing parameters. B. Resident #3 a) Refer to C160, the diet was clarified, education was provided to the direct care staff, order was updated on the MAR, service plan and hydration / plan were updated to reflect the accurate diet. 2. The system will be corrected so this violation will not happen again by: a) Ensuring all physician orders go through a triple check process where the orders are initially processed by the receiving med tech / RCC, to ensure no delay in treatment. Second check is the next oncoming med tech / RCC to verify orders are accurate, and appropiate directions and parameters for staff to follow are in place. Nursing to be the final check to verify all components are in place, and to make updates as indicated. b) All residents medications and treatments will be reconciled to ensure accurancy. c) Facility will compelete a parameter audit at least bi-weekly to ensure accurate administration and to identify medication-errors. 3.The area needing correction will be reviewed daily, weekly, and monthly basis with triple check MAR audits and monthly continuous quality improvement program to ensure MARs are accurate, including resident-specific parameters and instructions for medications. All orders will be reconciled quarterly prior to physician orders sent to MD for review. 4. The Administrator, Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate, including resident-specific parameters and instructions for medications, for 2 of 2 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the MCC with diagnoses including dementia. Residents 1's 07/01/26 through 08/17/26 MARs and current prescriber orders were reviewed, and the following was identified: * The resident was prescribed a nutritional supplement twice per day, as needed. The supplement was transcribed onto the MAR as scheduled twice per day; and * The resident was prescribed PRN bacitracin 500 unit/GM topical ointment (topical for infection) and PRN Vashe wound therapy (for wound care) that were not transcribed onto the MARs. The need to ensure MARs were kept accurate was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/20/26 at approximately 1:00 pm. They acknowledged the findings. 2. Resident 2 moved into the MCC in 05/2026 with diagnoses including Alzheimer’s disease with late onset and dementia. Residents 2's 08/01/26 through 08/17/26 MAR and current prescriber orders were reviewed, and the following was identified: * There were no resident-specific instructions for multiple PRN bowel medications, including sequence of administration; * A PRN order for CPS ABHR (a topical cream for agitation and/or aggression) lacked clear instructions for how long to wait between scheduled doses before using the PRN; * There were multiple scheduled and PRN Tylenol orders with instructions not to exceed 3000 mg per day; however, the total doses of scheduled and PRN Tylenol had the potential to exceed 8,450 mg per day; and * There were multiple duplicate orders transcribed on the MAR, including PRN Imodium transcribed twice and PRN loperamide, which was the same medication as the PRN Imodium. The need to ensure MARs were kept accurate was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/20/26 at approximately 1:00 pm. They acknowledged the findings.

C310 OAR 411-054-0055 (2) Systems: Medication Administration 1. Immediate action taken to correct the rule violation: Resident #1 a) The nutritional supplement order has been changed to PRN as per the provider order. b)The PRN Bacitracin topical ointment and PRN Vashe wound therapy have been transcibed in the MAR to the match the provider order. Resident #2 a) The following PRN bowel medications have been discontinued for non-use: PRN Bisacodyl Suppository, PRN Fleet Enema, & PRN Milk of Magnesia times two. b) The PRN CPS ABHR (a topical cream for agitation and / or aggression) has been discontinued by the provider. c) PRN Actaminophen every 6 hours has been discontinued. PRN Actaminophen every 4 hours has had the following parameters added 'may administer one dose between routine doses not be administered within 4 hours of routine dose. d) PRN Loperamide has been discontinued. 2. The system will be corrected so this violation will not happen again by a) Ensuring all physician orders go through a triple check process where the orders are initially processed by the receiving med tech / RCC, to ensure no delay in treatment. Second check is tht next oncoming med tech / RCC to verify orders are accurate, and appropiate directions and parameters for staff to follow are in place. Nursing to be the final check to verify all components are in place, and to make updates as indicated. b) All resident medications and treatments will be reconciled to ensure accurancy and clear instructions for staff to follow. 3.The area needed correction will be reviewed daily, weekly, and monthly basis with triple check MAR audits and monthly continuous quality improvement program to ensure MARs are accurate, including resident-specific parameters and instructions for medications. All orders will be reconciled quarterly prior to physician orders sent to MD for review. 4. The Administrator, Licensed Nurse, RCC or trained designee will be responsible to ensure the corrections are completed and monitored.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the RCF took measures to prevent the entry of rodents, flies, mosquitoes, and other insects, ensure the RCF grounds were kept orderly and free of litter and refuse and garbage was stored in covered containers. Findings include, but are not limited to: During a walkthrough of the exterior environment on 08/17/26 at 11:15 am and 08/18/26 at 8:30 am, including the secured memory care courtyard, the following was identified: * The front lawn and around the front patio were littered with garbage, broken game equipment, and furniture that was not appropriate for outdoor use; * The front lawn and courtyard lawn and shrubs were overgrown; * Landscaping and planting beds were littered with various garbage; and * There were threadbare and/or torn screens on multiple windows. The need to ensure the RCF took measures to prevent the entry of rodents, flies, mosquitoes, and other insects, ensure the RCF grounds were kept orderly and free of litter and refuse and garbage was stored in covered containers was discussed with Staff 1 (Administrator) during a walkthrough of the exterior environment on 08/18/26 at 9:30 am. She acknowledged the findings.

C510 OAR 411-054-0200 (3) General Building Exterior 1. The actions taken to correct this rule violation as follows: a) The garbage, broken game equipment, and furniture that was not appropriate for outdoor use has been picked up and thrown in the dumpster on the front lawn and front patio. b) The front lawn and shrubs have been groomed / trimmed. c) The garbage has been removed from landscaped areas and planting beds. d) The threadbare and / or torn screens on mulitple windows will be repaired and / or replaced 9/30/26 2. The system will be corrected so this violation will not happen again by: a) All staff will have additional training on reporting maintenance concerns / issues via the use of the maintenance log. b) The maintenance director will review the maintenance log daily during stand up and ensure timely resolution. 3. The area needing correction will be evaluated by: The Administrator, Maintenance Director and / or RCC will conduct walk-throughs of the exterior of the community daily, weekly, monthly and will discuss concerns with IDT during daily stand up meetings as well as during quality improvement meetings. 4. The Facility Administrator, Maintenance Director, and / or designee will ensure the corrections are completed and monitored

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the interior and exterior environment was clean and maintained in good repair. Findings include, but are not limited to: The facility was toured on 08/17/26 through 08/18/26, and the following was identified: * The front entrance door was not secure to the door frame with gaps at the bottom of up to five inches when pushing on the door; * The front doorbell was broken; * Resident use spa and shower room floor was torn in multiple areas; * The caulking around the shower and the spa tub was deteriorating and had black matter build-up; * The toilet seat in the spa room was damaged; * Multiple gouges in the walls below the handrails throughout the facility; * Multiple resident unit doors and door jambs had gouges in the wood and/or paint; * The entire exterior siding and windows had build-up of debris, dirt, and cobwebs; and *The aluminum wrapped around the fascia board (below the rain gutters) was torn off in multiple areas, exposing the wood underneath; and * The rain gutters were overflowing with dirt, debris and weeds. The need to ensure the interior and exterior environment was clean and maintained in good repair was discussed with Staff 1 (Administrator) during a walkthrough of the exterior environment on 08/18/26 at 9:30 am. She acknowledged the findings.

C513 OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors 1. Actions taken to correct the rule violation are: a) The front entrance door has been ordered and will be installed upon delivery. b) The front doorbell has been installed. c) Resident use spa & shower room floor will be replaced with new vinyl by 9/18/26. d) Caulking around the shower and the spa tub will be repaired by 9/18/26. e) Toilet seat in the spa area has been installed. f) Multiple gouges in the walls below the handrails this is in process of being completed with an antcipated completion date of 10/10/26 g) Multiple resident unit doors and door jambs with gouges in the wood / paint this is in process of being completed with an anticipated completion date of 10/10/26. h) Exterior siding and windows with build up of debris, dirt and cobwebs this will be cleaned & pressure washed by 9/30/26. i) The aluminum wrapped around the fascia board (below the rain gutters) with exposure of wood is in process of being repaired and repainted. j) Rain gutters overflowing with dirt, debris and weeds have been cleaned. 2. The system will corrected so this violation will not happen again by: a) All staff will have additional training on reporting maintenance concerns / issues via the use of the maintenance log. b) The maintenance director will review the maintenance log daily during stand up and ensure timely resolution. 3. The area needing corrected will be evaluated by: The Administrator, Maintenance Director and / or RCC will conduct interior & exterior walk throughs of the community daily, weekly, monthly and will discuss concerns with IDT during daily stand up meetings, as well as during quality improvement meetings. 4.The Facility Administrator, Maintenance Director, and / or designee are responsible to ensure the corrections are completed and monitored.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the licensee failed to ensure adequate administrative oversight of operations which included supervision and training of staff. The facility’s failure to ensure quality of services provided to residents and a lack of supervision and oversight to staff performing job duties for 2 of 2 sampled residents (#s 1 and 3) put residents’ health and safety at risk. Findings include, but are not limited to: 1. During the change of ownership survey, conducted 08/17/26 through 08/20/26, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the scope, severity and number of citations. Situations during the survey were identified which posed a risk to residents' health and safety and constituted and immediate plan of correction in the following area: C160: OAR 411-054-0025 (4) Facility Administration: Operation. An immediate plan of correction was requested on 08/19/26 at 2:22 pm. The facility provided a plan of correction on 08/19/26 at 5:35 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. 2. Refer to deficiencies in the report.

Z140 OAR 411-057-0140 (1) Adminstration Responsibilites Refer to deficiencies in the report

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 160, C 231, C 295, C 510, C 513.

Z142 OAR 411-057-0140 (2) Administration Compliance Refer to: C160, C295, C510, & C513

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 300, C 303, C 310.

Z162 OAR 411-057-0160 2b) Compliance with Rules Health Care Refer to: C300, C303, & C310

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an individualized nutrition and hydration plan for each resident was documented in the resident’s service plan for 2 of 2 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to: Resident 1 and 3’s service plans were reviewed. The service plans were found to be lacking information and staff instructions related to an individualized nutrition and hydration plan, including information regarding the resident’s prescribed modified diet textures, and instructions on how direct care staff were required to prepare meals, including snacks throughout the day. The need to develop an individualized nutrition and hydration plan for each resident and include it in the service plan was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 08/19/26 at 2:22 pm. They acknowledged the findings.

Z163 OAR 411-057-0160 (2)(c (A)(B) Nutrition and Hydration 1. The action taken to correct the rule violation include: a, Resident 1 and 3's service plan has been updated to include, but not limited to: individualized nutrition and hydration plan including information regarding the resident's modified diet textures and instructions on how direct care staff are required to prepare meals, including snacks through out the day. 2. The system will be corrected so this violation does not happen again by: a. Conducting a 100% audit of all current residents' service plans. Any plan lacking specific details will be updated to include an individualized nutrition and hydration plan that identifies required diet textures and instructions for meals and snacks. b. All newly admitted resident's will be evaluated by the licensed nurse or designee prior to admission to ensure all individulaized hydration and nutrition plan is developed. This plan will be evaluated within 30 days of move-in, quarterly, or with changes of condition to reflect the specific diet textures and instructions on how direct care staff are required to prepare meals, including snacks through the day. 3. The areas needing correction will be monitored by the service planning team after the initial, 30 day, quarterly, and upon change of condition service plan. 4. The Administrator, Licensed Nurse or designee are responsible to ensure the corrections are completed and monitored.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: